Medicare is the federally sponsored health insurance plan in the United States that covers adults over age 65 and certain adults under 65 who have disabilities. It covers a share of the cost for a range of medical services, including inpatient hospital care and prescription drug coverage, to make medical care more affordable for American citizens.
Receiving the necessary medical care when living with multiple sclerosis (MS) can be very costly. A study found the average lifetime costs of treating MS to be over $2 million. Many people with MS take prescription medications and undergo different therapies to slow disease progression. People with MS can receive assistance paying for health care for their condition through Medicare.
There are various ways to qualify for Medicare. People above the age of 65 may be eligible, regardless of whether they receive Social Security or Railroad Retirement Board benefits. Additionally, people under the age of 65 can be eligible if they have received Social Security disability benefits for at least 24 months. Notably, the U.S. Social Security Administration (SSA) recognizes MS as an impairment for which you may be eligible to receive disability benefits.
This article covers the basics of Medicare for people living with MS. If you have additional questions, you can contact the National MS Society for free assistance in understanding your Medicare options.
Medicare is organized into four different parts. Original Medicare is the combination of Medicare Parts A (hospital insurance), B (medical insurance), and D (drug coverage). These are all covered by the federal government. Medicare Part C plans — sometimes referred to as Medicare Advantage plans — are an alternative to Original Medicare. They’re offered by private insurance companies that are approved by Medicare.
Following is a summary of services covered by each Medicare part.
Medicare Part A, or hospital insurance, covers inpatient hospital care, such as:
Medicare Part B, or medical insurance, covers:
Medicare Part C acts as an alternative to Original Medicare. It includes private Medicare Advantage plans which you can choose to enroll in. Plans under Part C work differently from Original Medicare and have different coverage and costs based on the plan you select.
Medicare Part D provides limited prescription drug coverage.
If you have MS, you will likely qualify to receive Medicare coverage either when you turn 65, or before you turn 65 if you are on disability benefits. Ways for enrolling in different parts of Medicare are described below.
If you’re over 65 and receive benefits from Social Security or the Railroad Retirement Board (RRB), you will automatically be enrolled in Parts A and B when you turn 65. Medicare will send you a “Welcome to Medicare” packet and a red, white, and blue Medicare card three months before your 65th birthday.
If you are under 65, have a disability, and have received Social Security disability or RRB benefits for at least 24 months, you will automatically be enrolled in Parts A and B. You should also receive a welcome packet and Medicare card three months before your 25th month of enrollment in Social Security or RRB benefits.
You do not need to sign up for Medicare each year, but you will have the opportunity each year to change or cancel your plan during the Open Enrollment period from Oct. 15 to Dec. 7.
If you are diagnosed with MS, you will likely want to enroll in a prescription drug coverage plan through Medicare Part D. There is no automatic enrollment for Medicare Part D, so you may shop for and compare drug plans through the Medicare Plan Finder. Once you have selected a drug plan, you may enroll through the Medicare site or the plan’s website.
In selecting a Medicare Part D drug plan, you will want to check the plan’s formulary, or list of covered drugs, to make sure that your prescription drugs are included. Some MS drugs are very expensive. To protect yourself from those high costs, look for drug plans that offer coverage in the coverage gap — a temporary limit on what drugs a plan will cover. The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs.
If you would like to forgo Original Medicare and sign up for a private Medicare Advantage plan, you may do so during a seven-month period. The period includes the three months before and three months after you start getting Parts A and B. To shop for plans, Medicare’s Plan Finder Tool is a good place to start.
If you were automatically enrolled or signed up for Medicare Parts A and B, you still have the option to change your plan. You can do so either during the seven-month window you were initially eligible or during one of the two other enrollment periods. The first is the Open Enrollment period, which runs from Oct. 15 through Dec. 7, and for which coverage starts on Jan. 1. The second is the Medicare Advantage Open Enrollment period, from Jan. 1 through March 31. During this period, you may switch one time to a different Medicare Advantage plan or to Original Medicare.
Previously, people with chronic, stable conditions like MS could be denied specific Medicare services, like physical therapy, on the grounds that such services would not improve one’s condition or quality of life. However, in 2013, a judge approved a settlement in the Medicare Improvement Standard case, which made it illegal to deny potential Medicare beneficiaries coverage based on the Improvement Standard — that is, on the grounds that their chronic condition was stable and not capable of improving further. This settlement made it so that people with MS, for example, could not be denied skilled maintenance nursing or therapy services.
However, the National MS Society notes that sometimes a person with MS will still have to advocate for themselves to receive coverage for condition-related treatments and therapies.
If you are seeking Medicare coverage but are denied or given trouble because of your condition, know that you are legally entitled to an assessment of your individual health needs in order to determine your qualification of coverage.
The cost of drugs for treating MS may be difficult to manage. If you have MS and are on Medicare or will be enrolling in Medicare soon, you have several options for prescription drug coverage.
Medicare covers different types of drugs, such as pills or infusions, in different ways. Any prescription oral medications or medications you can self-administer at home, like injections, would be covered under a Part D drug plan or a Medicare Advantage plan — if the specific drug is covered by that plan.
For treatment of MS, drugs administered through infusions or those used to treat relapsing MS will be covered differently than oral medications used to slow the progression of MS. Any infusion drugs that you receive at a medical facility would be covered under Part B. If you are hospitalized during a relapse and receive medication during your hospital stay, those drugs would be covered under Part A.
If you need additional financial assistance for your medications and are already enrolled in a Medicare prescription drug plan, the Social Security Administration offers extra help with premiums, copayments, and deductibles. You can learn more and fill out an application for coverage on the SSA website. If you are low-income, you may qualify for Medicaid. You can also explore different Patient Assistance Programs, which are offered by drug manufacturers to help people pay for their medications.
Since MS is a chronic, progressive condition, people with the disease may need additional and new types of health care services to retain their quality of life and to function as they age. People with MS may receive services covered by Medicare — with certain stipulations, applicable to anyone on Medicare and living with a chronic condition. They may receive services like physical, occupational, and speech therapy — as long as the services are deemed to be skilled services, medically necessary, and within Medicare’s expense limits.
Skilled nursing care is care administered in skilled nursing facilities (SNFs). Although these services are covered under Medicare, the number you may receive is limited to the length of your stay at a facility. People with MS may need skilled nursing care after a hospitalization for a relapse. During their stay at an SNF, people with MS can receive care like physical and occupational therapy to aid in recovery from a relapse.
Medicare will only cover up to 100 days of care in an SNF, with full coverage for the first 20 days, and only partial coverage for the remainder. To be eligible, a person must meet certain requirements to show that their care was medically necessary.
The National Multiple Sclerosis Society explains that the SSA will sometimes deny Medicare coverage for skilled nursing care to people with chronic conditions like MS. As noted, Medicare may deny coverage on the grounds that a particular treatment may not result in a person’s condition improving. However, people with conditions such as MS are legally entitled to certain types of care, and the National MS Society provides important advocacy tips for you or a loved one in case coverage is denied.
People with MS who need more advanced daily care may qualify for home health benefits under Medicare. For home health care to be covered by Medicare, the services must be deemed medically necessary, and criteria like being homebound must be met.
Services provided for home health care include:
Finally, a person with MS may receive long-term care from Medicare through the hospice benefit. The hospice benefit, however, is reserved for people who have been medically evaluated to be terminally ill.
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